Delay in talking

Language is the process whereby we communicate with others. It involves an element of understanding and expression (speech). It is one of the most highly developed of all human skills, giving us a framework for thought and allowing us to communicate. Disorders of speech and language are common, ranging from unclear speech or a slight delay in development to more significant difficulties associated with serious disorders.

This article will give you an outline of the normal development, assessment of the child presenting with these difficulties and some of the more common causes.

Normal speech development

The following is only a rough guide but there is a wide variation of normal speech development¹²:

• 1-6 months: turns to sound, startled by loud sounds, cooing and babbling sounds. Copies smiles and laughs. Different sounds for different needs.

• 6-12 months: babbling - initially 'da', 'ba' then combining syllables towards 7/8 months - 'da-da', 'ba-ba'.

• 12 months: says 'mama', 'dada' or another simple word with meaning.

• 12-18 months: vocabulary of 6-20 words, not necessarily understood by unfamiliar adults; pretend play - for example, pretending to talk on the phone.

• 18-24 months: vocabulary of 50 or more single words, two-word phrases; more of speech is now understood by strangers.

• 2-3 years: vocabulary of around 300 words, including names. Three- to five-word sentences, use of pronouns, starts to use plurals and past tense, begins to talk incessantly. Long words may be shortened - eg, 'nana' for 'banana'. Can identify some body parts or objects in a picture.

• 3-4 years: three to six words per sentence; asks and answers questions, relates experiences, tells stories; almost all speech understood by strangers. Errors with tense are normal - eg, 'runned' instead of 'ran'.

• 4-5 years: six to eight words per sentence; names four colours; counts to ten.

Variations in development versus delay

It is important to clarify what the concern is, as there can be a lot of variation in speech and language development. Consider whether either of the parents was a late speaker. There tends to be a gender difference with girls developing slightly faster than boys and it is traditionally said that bilingualism may delay speech (although there is emerging evidence to the contrary³and the end result is thought to be the same)⁴. Parents are usually the first to express concern - are they comparing to other children and simply observing normal variation? The health visitor may also refer the child. Examples of the need for referral include:

• There is no double syllable babble at a year.

• There are fewer than six words, or there is persistent drooling, at 18 months.

• There are no two- to three-word sentences by 2½ years.

• Speech remains unintelligible by 4 years.

Epidemiology

• Speech delay is a common childhood problem. It is estimated to affect around 6% of children⁵. However, this figure has been reported to be as high as 19%⁶.

• The disorder is more common in boys than in girls.

Aetiology⁶

Primary

• Primary speech and language delay. Delay is not caused by other conditions. Children have normal understanding, intellect, hearing, emotional relationships and articulation skills.

• Expressive language disorder. Needs active intervention to improve.

• Receptive language disorder.

Secondary

Problems can arise from:

• Speech or articulation difficulties:
  

  • Cleft lip.

  • Tongue tie.

  • Stammer.

  • Cerebral palsy (can cause delay for several reasons).

• Deafness.

• Developmental problems:
  

  • Maturational delay (often familial).

  • Environmental deprivation and neglect.

  • Learning disability.

  • Cerebral palsy.

• Communication difficulties:
  

  • Autism.

• Other:
  

  • Selective mutism (the child selectively refuses to speak according to particular circumstances).

  • Childhood apraxia of speech. Difficulty in making the right sounds in the correct order.

  • Dysarthria. Motor difficulty in creating speech.

Assessment

Assessment of the child to answer these questions can be complex - particularly beyond toddlerhood - and a speech and language therapist assessment may also be required.

History

These children may be particularly shy about talking, so obtain a good history from the parents.

• Establish whether the child appears to have difficulty in hearing.

• Note whether the child seems to understand what the parent is saying. If they seem to understand, but respond with unintelligible speech, there is a speech problem. If there are comprehension difficulties too, there may be a language or other problem.

• Note whether there are delays in other physical or social skills which could suggest a more global delay.

• Establish whether there are abnormalities in nonverbal communication skills that might suggest autism.

• Obtain a complete developmental history.

• Check the past medical and perinatal history.

• Ask about a family history of deafness or language delay.

Examination

• Observe the child play and interact with the parent. Listen to any talking and note any imaginative play:
  

  • A stammer is associated with normal comprehension; however, speech is immature, stuttered or unintelligible.

  • Note that the ability to form interpersonal relationships is often normal in children with learning difficulties, as it is in all other causes except for autism.

  • Autism and language disorders may both be associated with delays in other developmental areas.

• Ask the child simple questions about pictures or their play: note whether they seem to understand you. Assess motor and social skills.

• Note any anatomical abnormalities, and examine mouth and ears. Exclude tongue tie as a cause.

Investigations

Organise a formal hearing test by an audiologist. If you think that there is some sort of language difficulty following your assessment, get a speech and language evaluation too.

Management

• Management may sometimes be just explanation, simple advice and reassurance with the involvement of the health visitor.

• However, early detection and intervention for speech delay may prevent, or at least reduce, the educational, emotional and social problems that may be caused.

• A referral for speech therapy may be required. The effectiveness of therapy depends upon the cause for speech delay. There is some evidence for the effectiveness of interventions for expressive speech difficulties; the evidence for interventions for expressive syntax is mixed and there is no evidence for interventions for receptive language difficulties⁵.

• There is currently no strong evidence for the best treatment of childhood apraxia of speech⁷. Also, there is no convincing evidence that speech and language therapy is effective for early acquired dysarthria⁸.

• Multidisciplinary involvement may be required and the involvement of the parents is vital.

• Management is dependent on cause and associated problems such as hearing impairment.

• If the underlying problem is related to the auditory apparatus and surgery is required, children still need targeted language therapy to complete their rehabilitation⁹.

There is no systematic child development and behaviour screening policy in place in the UK¹⁰. The evidence on screening for developmental delay in asymptomatic children aged 1-4 years is inconclusive¹¹.

Prognosis

• This is dependent on the cause of the speech delay.

• The prognosis is improved with early detection and intervention.